In recognition of the need to take a more holistic approach to sexual and reproductive health and rights, the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights convened in 2016. Composed of 16 experts from Africa, Asia, Europe, the Middle East, and North and South America, the Commission set out to gather the most current evidence on sexual and reproductive health and rights at the global level, with the aim of driving transformational change through policy and political action. Its resulting report, released in May 2018, reveals enormous gaps in sexual and reproductive health and rights worldwide, and quantifies the toll those gaps take on individuals, countries and regions as a whole. The Commission’s report presents a new, comprehensive definition of sexual and reproductive health and rights, which integrates the full range of people’s sexual and reproductive health needs and is grounded in human rights principles. It also presents a package of essential sexual and reproductive health interventions, including the right to safe abortion care. This commentary focuses on the inclusion of safe abortion as a fundamental component of sexual and reproductive health. It describes global trends in abortion legality and safety, as well as barriers to the provision of abortion services. Finally, it highlights the status of the right to safe abortion in the international human rights framework.

In March 2018, the Democratic Republic of Congo moved to enact the Maputo Protocol, under which signatory states agree to authorize legal access to abortion in a range of circumstances. Two months later, voters in Ireland delivered a decisive victory for reproductive rights, choosing overwhelmingly to repeal the country’s near-total ban on abortion. And the following month, Argentina’s lower house of Congress voted in favor of a draft bill that would permit abortion up to 14 weeks; although the upper house narrowly rejected the legislation, this was the closest the country ever came to legalizing abortion. While progress remains uneven, these developments speak to a shifting consensus on abortion rights around the world, and unfold alongside mounting efforts of advocates to position safe and legal abortion as a human right.

The seeds of this shift were planted in Cairo in 1994. Until the International Conference on Population and Development (ICPD) that year, there had not been a global agreement that created common language on sexual and reproductive health, or on the rights people have when it comes to making reproductive decisions. The Programme of Action that emerged from ICPD mapped out the linkages between social and economic growth, sustainable development, and individual and collective well-being. It also identified key components of sexual and reproductive health care, which included the provision of safe abortion services in settings where such care is not against the law.

Since 1994, more than 30 countries, many in the developing world, have amended their laws to expand access to safe and legal abortion. Nonetheless, abortion is often viewed as a separate domain entirely, rather than as a core component of sexual and reproductive health care. This lack of integration makes it much easier to neglect, and in some cases exclude, abortion care in both programming and policy-making. In recognition of the value of taking a more holistic approach to sexual and reproductive health and rights, the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights convened in 2016. Composed of 16 experts with multidisciplinary experience from Africa, Asia, Europe, the Middle East, and North and South America, the Commission set out to gather the most current evidence on sexual and reproductive health and rights at the global level, with the aim of driving transformational change through an evidence-based agenda focused on policy and political action.

Its resulting report, released in May 2018, reveals enormous gaps in sexual and reproductive health and rights worldwide, and quantifies the toll those gaps take on individuals, countries and regions as a whole. The Commission’s report presents a new, comprehensive definition of sexual and reproductive health and rights, which integrates the full range of people’s sexual and reproductive health needs. Drawing on international and regional agreements of the past 25 years, this new definition highlights the fact that achievement of sexual and reproductive health relies on realization of sexual and reproductive rights, which are themselves human rights. The report calls on governments, UN agencies and civil society to embrace elements of sexual and reproductive health and rights that are rarely addressed in global discussions, including the right of all people to make decisions about their bodies—free of stigma, discrimination and coercion. It highlights specific populations whose sexual and reproductive health needs must be better understood and served, including people of diverse sexual orientations and gender identities, displaced people and refugees, and people with disabilities.

The report also puts forth a package of essential sexual and reproductive health interventions. The package includes interventions that governments typically focus on, such as contraceptive services, HIV prevention and treatment, and maternal and newborn health services. It also incorporates frequently overlooked components of sexual and reproductive health— prevention and detection of gender-based violence, and counseling services for people who have experienced such violence, for example, as well as safe abortion care.

There is more to abortion safety than medical safety; that is, an abortion can be considered safe only if a person can have one without risk of criminal or legal sanction, and without enduring repercussions from family or community members. While the evidence is insufficient to fully evaluate both the medical and the nonmedical dimensions of abortion safety, increased access to safer methods (e.g., medication abortion) in settings with restrictive abortion laws has facilitated a more nuanced measure of abortion safety than was articulated in the past. Abortion is considered safe when it is performed by a trained person and it is carried out via a method recommended by the World Health Organization, less safe when only one of these conditions is met and least safe when neither condition is met. Together, less safe and least safe abortions make up unsafe abortions. Under these criteria, an estimated 25 million unsafe abortions took place each year during the period 2010–2014; that number represents 45% of all abortions that occurred during those years.

When it comes to abortion care, safety and legality are inextricably linked. The vast majority of abortions are safe in countries where abortion is broadly legal, while most are unsafe in countries where it is highly restricted. What is less widely recognized is the relationship between legality and overall incidence of abortion. The newest data establish that restricting access to abortions is not associated with a lower abortion rate. In reality, the average abortion rate for the group of countries where abortion is prohibited altogether or allowed only to save a woman’s life is 37 abortions per 1,000 women of childbearing age; by contrast, in places where abortion is legal, the rate is 34 per 1,000.

Including safe abortion services as part of an essential package of health interventions is a critical step toward expanding access to high-quality and affordable care, but ensuring the overall well-being of a person who has an abortion requires more than a medically safe procedure in a legal setting. Stigma represents a pervasive yet understudied barrier to safe abortion care, and persists in countries with both liberal and restrictive legislation. The stigma associated with abortion can profoundly affect women’s mental and physical health, as well as undermine medical providers’ willingness to perform the procedure. For example, a systematic review found negative attitudes toward abortion among a substantial number of health providers across Southeast Asia and Sub-Saharan Africa. Providers’ refusal to perform abortions continues to impede women’s legal right to safe abortion in many places.

Whether through concrete legal barriers or through less visible barriers, like stigma, the denial of abortion care conflicts with numerous principles enshrined in international human rights frameworks. Perhaps most fundamental, international law maintains that all people have the right to “the highest attainable standard of physical and mental health.” This affirmation has global relevance: Every country has ratified at least one international human rights treaty recognizing the right to health. In doing so, governments have committed to creating conditions that are conducive to the enjoyment of good health.

These protections extend to sexual and reproductive health, and entail the same mutually reinforcing freedoms and entitlements that are core to the fulfillment of other universal human rights. In this case, these freedoms encompass the right of individuals to make autonomous choices concerning their own bodies, sexuality and reproduction. The entitlements include unhindered access to health facilities, goods, high-quality services and accurate information that enable people to realize their right to sexual and reproductive health.

Over the past few years, countries have made important strides toward expanding the legal right to safe abortion care, often with support and guidance from regional consensus agreements—Africa’s Maputo Protocol, Latin America and the Caribbean’s Montevideo Consensus, and others. Although these agreements differ in scope and approach, they embrace the right to safe abortion care more robustly than any previous ones did, urging states to consider expanding the grounds for legal abortion and to ensure high-quality services where abortion is legal. In the end, defining abortion as a fundamental component of sexual and reproductive health care will require moving beyond policy to implementation—that is, from legally establishing rights to making safe abortion services available and accessible. In its new definition and package of essential interventions for sexual and reproductive health and rights, the Guttmacher-Lancet Commission brings together components of policy and practice that were not previously part of a unified whole. In so doing, it offers a bold, comprehensive and actionable vision that places bodily autonomy and self-determination front and center.

Acknowledgment

The report on which this commentary is based was made possible by support to the Guttmacher Institute from the Dutch Ministry of Foreign Affairs, UK Aid from the UK Government, the Norwegian Agency for Development Cooperation, The William and Flora Hewlett Foundation, the Swedish International Development Cooperation Agency, the German Federal Ministry for Economic Cooperation and Development, and The David and Lucile Packard Foundation. The findings and conclusions in the report are those of the authors and do not necessarily reflect the positions and policies of the donors.

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